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<br />Proposal of Insurance For Naveed Haider, M.D. <br />Page 9 of 16 <br /> <br />Other Terms and Conditions: <br /> <br />Named Insured List: Medical Malpractice <br />Note: Any entity not named in this proposal may not be an insured entity. This includes partnerships and joint ventures and trusts. <br /> <br />Estimated Annual Policy Premium: Medical Malpractice <br />Estimated Annual Policy Premium Medical Malpractice <br />Premium, Taxes and Fees $5,000.00 Premium <br /> $93.63 Surplus Lines Tax <br /> $350.00 Policy Fee <br />ESTIMATED PROGRAM COST $5,443.63 Total <br />Minimum Earned Premium Policy premium is subject to a minimum earned of twenty-five (25%) of the total premium. <br /> <br />Claim Reporting Procedures <br />See page 6 of the attached sample policy to review the claim reporting procedures. Claim Reporting Address: Kinsale Insurance Company, 6802 <br />Paragon Place, Suite 120, Richmond, Virginia 23230 <br />Condition <br />See attached policy form for exclusions and limitations of coverage. <br />Policy Terms and Conditions – please review policy for complete details <br /> Option 1 <br />Consent to Settle w/ Limitation Included <br />Deductible Applies to Indemnity and/or Claims Expenses Included <br />$25K Data Breach Expense Reimbursement Included Defense within the Limit Included $25K HIPAA Related Expense Reimbursement Included <br />No Punitive Damages Included <br />Risk Management - please provide email address to activate this free service Inc <br />MPL2030 - Cass County Jail; 450 34th Street S, Fargo, ND 58103 MPL2027 - Nurse practitioners or Physicians Assistants unless specifically named by an endorsement to the policy. <br />THIS MAY INCLUDE ONE OR MORE COVERAGES FOR A CLAIMS MADE AND REPORTED POLICY. THE COVERAGE REQUIRES THAT A CLAIM MUST BE FIRST <br />MADE AGAINST AN INSURED DURING THE POLICY PERIOD AND BE REPORTED IN WRITING TO THE COMPANY WITHIN THE POLICY PERIOD OR AN <br />EXTENDED REPORTING PERIOD, IF APPLICABLE. IF YOUR POLICY PERMITS REPORTING OF INCIDENTS, THEN INCIDENTS MUST BE REPORTED WITHIN <br />THE POLICY PERIOD. PLEASE REFER TO SECTION V-ADDITIONAL TIME IN WHICH TO REPORT CLAIMS FIRST MADE AT THE END OF THE POLICY PERIOD. PLEASE READ THE ENTIRE POLICY CAREFULLY. Please note that this quote INCLUDES risk management services for no charge. Additional risk management services are also available for purchase - see brochure <br />included or contact OmniSure for details. PLEASE PROVIDE YOUR EMAIL ADDRESS AT BINDING TO ACTIVATE THESE FREE RISK MANAGEMENT SERVICES. <br />Policy Form and Endorsements – Policy Forms & Endorsements correspond to the included Terms & Conditions of OPTION 1 (please consult with your underwriter should you need specimens of optional terms and conditions) MPL1001-1115 - Declarations <br />Medical Professional Liability - Claims Made and Reported <br />ADF9013-0815 - Notice - Where To Report A Claim <br />ADF4001-0110 - Schedule of Forms <br />MPL0001-1115 - Medical Professional Liability Policy MPL2027-0513 - Amendment - Designated Specialist(s) Who Are Not "Insureds" <br />MPL2030-1213 - Entity And Location Limitation <br />MPL2031-0214 - Non-Stacking Limitation <br />MPL2034-1015 - Endorsement - Part-Time Practice <br />MPL4001-0413 - Minimum Policy Premium MPL4002-0515 - HIPAA Related Expense Reimbursement Endorsement MPL4004-0515 - Data Breach Expense Reimbursement Endorsement <br />MPL3005-0110 - Exclusion- Obstetrics or Surgery <br />ADF9004-0110 - Signature Endorsement <br />ADF9009-0110 - U.S. Treasury Department's Office of Foreign Assets Control (OFAC) Advisory Notice to Policyholders <br />All other exclusions and restrictions of the policy that are not addressed in this proposal will apply to coverage. <br />Insured Specialty Retro Date Eff. Date Limit Per Claim Policy Aggregate <br />Naveed Haider, M.D. Psychiatry 11/01/2016 11/1/2016 $1,000,000 $3,000,000